The incidence of heart failure (HF) in the United States is approaching 5 million patients with approximately 550,000 new cases identified each year.1 In addition, the prevalence of HF increases with age, such that for patients 55 to 64, 65 to 74, and 75+ years, the incidence of HF is 8.1%, 10.3%, and 20.7%, respectively.1 Heart failure as a common chronic syndrome in the geriatric population challenges healthcare providers in the provision of patient care and improvement of patient outcomes. The purposes of this article are to (1) describe medication use and its associated challenges and (2) discuss hospitalization and outpatient management for older adults with HF with the goal of improving patient outcomes.

A search for articles related to these 2 topics was undertaken for the period 1990 to 2005, supplemented by additional searches of article reference lists and scans of cardiovascular and HF journals. The search for appropriate articles was undertaken using Medline and Citations in Nursing and Allied Health Literature. The key words used were heart failure, elderly, and older adults cross-referenced with medications, noncompliance, discharge planning, hospital readmission, and disease management. The search was focused by only including articles for adults 65 years or older. Titles of articles and abstracts were reviewed to determine if they focused on the selected topics. The search was not exhaustive because this article was not intended to provide an in-depth critique of the literature, but rather to provide insight into the special issues facing older adults with HF regarding medication use and management in both the hospital and outpatient environments.

Medication Use in Older Adults With HF

There are many issues that increase the complexity and challenges of medication prescription and use in older adults with HF. Three key issues include drug profiles (safety, efficacy, and adverse effects), comorbid conditions, and potential for medication nonadherence.

Regarding HF drug profiles, older adults have not been well-represented in large-scale, randomized controlled trials (RCTs) designed to test the safety and efficacy of HF medical therapies.2 Thus, concerns exist regarding the risks and benefits of these drugs in older patients, specifically regarding responsiveness to these drugs and adverse effects. Interestingly, recent non-RCTs have reported that these medications are both safe and effective while being underprescribed in older adults.3,4 Masoudi et al3 and Pedone et al4 reported angiotensin-converting enzyme (ACE) inhibitor prescription rates of only 68% and 67%, respectively, at hospital discharge of older adults with HF, and yet, subsequent reductions in mortality with ACE inhibitor use 12 to 15 months' posthospital discharge.

Furthermore, in another non-RCT, combined ACE inhibitor and beta-blocker use in older adults (n = 779) as compared with older adults having no prescription for ACE inhibitors or beta blockers (n = 5,497) resulted in decreased mortality (1-year mortality = 16.6% vs 29.9%, respectively).5 In a secondary analysis of an RCT (Assessment of Treatment with Lisinopril and Survival), 3,164 patients (mean age, 64 +/- 10 years; 27%, >=70 years) who were randomized to receive low-dose or high-dose ACE inhibitor (lisinopril) were studied regarding their nonrandomized use of beta blockers and digoxin.6 Researchers concluded that compared with low-dose ACE inhibitor use, high-dose ACE inhibitor use plus beta blockers and high-dose ACE inhibitor use plus beta blockers and digoxin resulted in an incremental decrease in all-cause mortality or hospitalization for any reason 1 year later. Thus, although trends have suggested an increased use of ACE inhibitors and beta blockers since 1989 in adults 65 years or older7 (which supports existing practice guidelines), these drugs are still underutilized and underdosed in older adults (adjusting for patients with side effects and contraindications). It seems that it is time to follow HF guidelines when managing these older adults and consider the design of RCTs of HF drugs in this special population.

And yet, a few words of caution related to adverse effects and comorbid conditions are needed. This caution is best exemplified in a report8 from a recent analysis of computerized prescription records of HF patients 65 years or older, examining trends in the rate of spironolactone use before and after the publication of the Randomized Aldactone Evaluation trial.9 Although the Randomized Aldactone Evaluation trial demonstrated reduced morbidity and mortality with the use of spironolactone in HF patients,9 subsequent increased use of spironolactone in clinical practice resulted in increased hyperkalemia-associated morbidity and mortality.8 The researchers speculated that reasons for the increased incidence of hyperkalemia may have included lack of careful monitoring of serum potassium, lack of awareness of medications or other comorbidities (eg, diabetes) that increase serum potassium, inappropriately prescribed high doses, and undetected conditions that may develop during therapy (eg, renal dysfunction).8 Thus, in older adults with HF and other comorbidities who typically require polypharmacy, although the benefits of new HF drug therapies as reported from large RCTs are apparent, careful selection of patients for specific drug therapies, awareness of comorbidities, and careful monitoring of drug interactions, adverse side effects, and serum laboratory values cannot be overemphasized.

A third challenge in medication use by older adults is medication noncompliance. Factors that may be related to medication noncompliance in older adults with HF include polypharmacy, frequent daily dosing, complexity of a medication dosing regimen, adverse effects of medications, difficulty taking medications (eg, swallowing large pills), cognitive impairment (eg, memory and attention deficits), sensory impairment (eg, visual and auditory), low literacy, social isolation, lack of motivation, depression, and medication costs.10-12 Understanding these factors provides direction for the development of strategies to increase patient medication adherence.

Strategies to increase compliance with taking medications include identifying individuals at risk for noncompliance; tailoring medication regimens to an individual's lifestyle; monitoring strategies (ie, pill boxes); reminder strategies (ie, setting an alarm clock at times medications are to be taken); social support; and regular follow-up through clinic visits, telephone, mail, and/or home visits.10 In addition, it is incumbent upon healthcare providers to educate patients and caregivers about their medication regimen and discuss individualized, successful ways to implement the regimen. Lack of education by professionals is an unacceptable cause of patient noncompliance.

Hospitalization and Outpatient Management of Older Adults With HF

Heart failure is the most common reason for hospital readmission in older adults,13 and rates of hospital readmission within 6 months of the index hospitalization approach 50%.14 Heart failure accounts for substantial use of hospital resources at an aggregate cost of $8 billion.15,16 Using medical record review and multivariable analyses, Krumholz et al17 identified 4 predictors of hospital readmission in older adults: prior admission within 1 year, prior HF, creatinine level >2.5 mg/dL, and diabetes at discharge. Researchers have also identified preventable causes of hospital admission related to behavioral and psychosocial factors. Noncompliance with medications and diet has been identified as a preventable cause of hospital admission in older adults with HF as early as the late 1980s18,19 and as recently as the late 1990s.20,21

The impact of strategies to reduce hospital readmission rates has been tested and reported in the literature. Most of these studies have been RCTs that focused on older adults. To systematically evaluate the evidence supporting the effectiveness of strategies to decrease rates of rehospitalization, meta-analyses of these RCTs have recently been reported. Strategies to reduce hospitalization rates have included comprehensive discharge planning with support after discharge (typically within multidisciplinary disease management programs) versus usual care. Meta-analyses revealed reduced rates of hospital readmission in older adults with HF patients when randomized to intervention versus usual care.22-27 These meta-analyses, thus, provide evidence that resource utilization (ie, rates of hospitalization) can be decreased significantly in older adults with HF with planned and focused interventions. Furthermore, sensitivity analyses conducted in 2 of the meta-analyses demonstrated similar results across RCTs regardless of the type of intervention.26,27

The discharge plan necessarily begins with an assessment of the HF patient/caregiver and environment. Sociodemographics (eg, the patient's home environment and financial resources for medical care); prior use of health and social services; general health, functional, mental, and emotional status; knowledge of HF and related self-care; prehospital compliance with the healthcare regimen; patient/caregiver needs and expectations at discharge, and assessment and need for outpatient follow-up (eg, return to clinic, home health nursing, extended care facilities, and nursing home care) are critical to the development of a focused plan of care.28

Approaches to care (identified in the RCTs) as part of comprehensive discharge planning and postdischarge management included patient and family education (including education on self-management strategies, ie, measurement of daily weights and diuretic adjustment), counseling (including strategies to increase adherence), clinic and/or home visits, telephone follow-up, mailings of HF educational materials, clinical monitoring of patient status, exercise regimens, and psychosocial support and/or social services consultation.22-27 These interventions were delivered by multidisciplinary teams including physicians and/or other expert healthcare providers (ie, nurse practitioners, physician assistants, pharmacists, dietitians, and social workers). The duration of intervention delivery varied by RCT and was from several weeks to more than 1 year.

Impact of Interventions on Outcomes of Older Adults With HF

The impact of discharge planning and HF disease management on outcomes (ie, mortality and quality of life) of older adults with HF has been studied fairly extensively during the last decade. However, findings from meta-analyses of many RCTs have been equivocal with regard to the impact of interventions on these patient outcomes. Some meta-analyses of RCTs provided evidence for the reduction of HF-specific mortality26 or all-cause mortality27 favoring the intervention group. Other meta-analyses of RCTs reported either no difference between groups22,23,25 or heterogeneous findings24 in rates of HF patient mortality. Phillips et al22 reported only a trend toward reduced all-cause mortality with a discharge planning intervention versus usual care, and Gawdry-Sridhar et al23 reported no affect of patient education interventions on mortality rates. Interestingly, McAlister et al24 reported that multidisciplinary team management reduced mortality, whereas programs that enhanced patient self-care activities or used telephone contact and follow-up with primary care practitioners evidenced no reduction in mortality.

Regarding quality of life, equivocal findings have also been reported. Using pooled quality of life data, Phillips et al22 reported significantly more improvement in quality of life from baseline to final follow-up in patients randomized to discharge planning interventions versus usual care in 6/18 RCTs. Gawdry-Sridhar et al23 did not have sufficient data to pool the 4/8 studies reporting quality of life data, although 2/4 studies reported improved quality of life from baseline to follow-up. Lastly, McAlister et al24 noted that of the 18 trials that assessed quality of life, 50% reported nonsignificant improvement from baseline to final follow-up. These analyses demonstrate the need for additional study of discharge planning and outpatient management interventions to improve both mortality and quality of life outcomes of older adults with HF.

Clinical Implications in the Care of Older Adults With HF

There are many clinical "pearls" that can be gleaned from the current body of literature regarding the use of medications and HF management in the population of older adults to improve patient outcomes. Whether patients are hospitalized or being followed at home, successful management of older adults with HF includes optimization of medical therapy as per HF practice guidelines2 with careful monitoring as medications are initiated and titrated. Successful management of HF medication use should also include patient and caregiver education regarding these medications (ie, purpose of medications, dosing regimen, side effects, self-management strategies, when to call the provider, and others). Furthermore, HF patient education needs to be supplemented with development of tailored behavioral strategies (in collaboration with the patient and caregiver) to enhance patient adherence with the HF regimen.

"Clinical pearls" related to management of patients in both the inpatient and outpatient setting in order to reduce in-hospital resource utilization and optimize patient outcomes can also be found in the literature. Discharge planning should include development of an individualized, comprehensive, multidisciplinary plan of care that begins immediately after hospital admission and is reevaluated at multiple times during the patient's hospitalization. Assessment of the patients and their living situation provide the cornerstone for a tailored plan of care. Patient and caregiver education is also an integral component of discharge planning. In addition to learning about HF medications, patients and caregivers should receive an explanation of HF, associated symptoms, and an action plan for worsening symptoms; self-monitoring of daily weights; dietary recommendations (ie, sodium restriction and fluid restriction, prn); activity and exercise recommendations (ie, activities of daily living, work, leisure activities, and sexual activity); and smoking cessation. Of critical importance is a plan for postdischarge patient follow-up, which is communicated (verbally and/or in writing) to the appropriate outpatient healthcare provider.

In addition, HF disease management programs with frequent and vigilant follow-up after discharge (including easy access to healthcare providers via telephone and regularly scheduled and "walk-in" clinic appointments, if needed) have demonstrated improvement in resource utilization and patient outcomes and, therefore, their usefulness in outpatient management.22-28 Given today's financial climate, efficiency, costs, and resource availability need to be considered in developing these programs (perhaps targeting populations at risk, including older adults).

It is incumbent upon healthcare providers to meet the challenge of providing HF care to older adults who often have unique needs in a way that is patient and caregiver centered, safe, efficient, cost effective, and that uses the latest practice guidelines. With the provision of optimal medical therapy and careful follow-up, older adults with HF can achieve good outcomes.

REFERENCES